Help with the mastectomy v. wide local excision decision!

trobenta · May 2012

I am 43 years old and was diagnosed with breast cancer at the end of November 2011, HER2+++. There was a 2cm tumour in the left breast (showing 3cm on the MRI) and 9mm away from it, there was a satellite lesion measuring 8mm. The sentinel node biopsy came back negative (some scattered cancer cells in the sentinel node, but none in the two non-sentinel nodes that were also taken out). On December 27 I was started on chemo - TCH protocol, 8 cycles. I'm to receive the last cycle in two days. Both the 'large' tumour and the satellite lesion are now completely gone. My oncoplastic surgeon is suggesting a breast conservation procedure using wide local excision to remove the tissue where the tumour was. Although it was said at the beginning that the satellite lesion would be removed with the main tumour, I'm still concerned whether this is sufficiently safe - the coil was inserted only into the main tumour, so there's no marking for the satellite one and the other concern is if a clear margin is left around both sites, how disfigured my breast would be (I have small breasts)?!

My oncologist first suggested mastectomy considering the tumour was aggressive and it was HER2+++, and also because of the satellite lesion, but subsequently changed his mind and said WLE could be performed and if the pathology test comes back clear, I had the same prognosis as a person who never had cancer (!), which is somewhat at odds with the recurrence rates I found on the Internet. In any case, he left it for me to decide and I cannot make up my mind - is recurrence much less likely if I do mastectomy; if I opt for WLE and have radiation afterwards and then at some point in the future the cancer comes back and I opt for mastectomy, would the radiation that I receive after this procedure compromise the possible implant reconstruction? Also, could I develop resistance to Herceptin, and is there a way around it if I do, which is as effective as Herceptin?

If anyone has any experience/knowledge/advice, I'd be very grateful.

Moderators · May 2012

Hi Trobenta,

While you wait for the ever-helpful advice from your fellow members here, you may be interested in checking out the main Breastcancer.org site and the Mastectomy vs. Lumpectomy page.

Hope this helps!

--The Mods

trobenta · May 2012

Thanks very much! I have already looked at that page and it is helpful, but I'm hoping for personal experiences to see if somebody is out there who was in the same situation and went for one or the other and how they feel now about their decision.

Thanks!

trobenta · May 2012

Anyone?

rozem · May 2012

hi

i had a very similar situation - I had chemo before surgery for a 2cm lump. Originally I was told that i would need rads whether i had a lumpectomy or mastectomy due to the fact that i had LVI (lymphovascular invasion) . At my hospital in canada they do not do immediate recon if you are having a msx. I decided to do the lump/rads and then do the the bmsx with recon after I healed. After my lumpectomy the pathology came back and I had pcr (no residual cancer left at the tumor site or nodes) -although i was told this was fantastic news I was never told that my prognosis was the same as someone who never had cancer as you were told. I have never heard this before. Anyway, after I had a complete response they told me i could go directly to a bmsx and skip rads. I decided on doing them anyway because that LVI component was really playing on my mind. I was told that my reconstruction would be comprimised and it will be. I met with my PS and I will have to do a lat/dorsi flap procedure on my radiated side (they take muscle from your back) I am having this done in september

it is a personal decision but i would also be concerned that the 2nd lesion was not "marked" - plus if you can skip rads by doing a msx then this is something to consider. If you are in the U.S then you will probably be able to do immediate reconstruction which is not an option that I had.

Also, I have never heard that a msx is recommended for her2 positive tumors due to the aggressiveness, it may have been recommended to you because the cancer was multi focal

you can PM if you need any further info

rozem · May 2012

sorry - i made a mistake on the post above - at my hospital they do not do immediate reconstruction if you are having rads

trobenta · May 2012

Thank you very much for your reply! This is really helpful. I have lots of thinking to do and every bit of info helps. I'm leaning towards lumpectomy, but the radiation is a big issue, both with regards to health and the future reconstruction if I have to have mastectomy after all. I really don't want the flap procedures, so implants are the only option, but with radiation, that's going to be difficult.

trobenta · May 2012

I suppose I cling to the fact that noone ever mentioned the cancer being multi focal, but rather they treated is as a single tumour for some reason - maybe the vicinity.

rozem · May 2012

sorry, didnt mean to freak you out about the mulitfocal aspect! i was just mentioning this because they did not mark the second lesion. You could always try the lumpectomy and do the mastectomy if your margins are not clear. Also after they do your final pathology from a lump they can see where the tumor was - there is a tumor bed (with hopefully dead cancer cells! praying that is the case for you) so they should be able to see where the second lesion was - you can ask your onc about this. If it was that close then they should be able to get it all. They took a 6x5x4 cm area for my 2cm tumor

rozem · May 2012

also - for the recurrance rates - local reaccurance is higher with a lump then msx - but my onc tells me that this is not as significant as it once was due to better pathology/surgical procedures - i was told in the single digits for a lump (8-9%) vs 1-3% with a msx. Distant reaccurance is the same whether you have a lump or msx

trobenta · May 2012

Don't worry, I can't possibly be more freaked out than I already am!

6x5x4 is a lot for a small breast. Even if I do go for WLE, who knows what the result will be. My surgeon told me they aimed for a 1cm margin. Maybe she'll decide there and then.

The recurrence rates I was told - up to 5% for mastectomy and 5-10% for lumpectomy.

I really appreaciate your help!

besa · May 2012

If you are concerned about the cosmetic results of a lumpectomy you could make an appointment with a plastic surgeon who specializes in breast reconstruction and oncoplastic surgery (NOT someone who does mainly cosmetic enhancements) - to get their opinion. Implants following radiation therapy is problematic but other reconstruction options DIEP, GAP, or Lumbar flaps work better after radiation.

trobenta · May 2012

Thanks besa. The surgery will be performed by an oncoplastic surgeon. She did not mention anything but when I voiced my concerns, she said that reconstructions can be done... Obviously, if I opt for the lesser operation, one of the reasons would be to avoid having multiple surgeries later on. If I end up with a considerable disfiguration, then mastectomy seems like a wiser option. This has been my dillema all along. Pros and cons keep 'jumping' form one column to the other!

Help with the mastectomy v. wide local excision decision!

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